title: Combined effect of cardiorespiratory fitness and adiposity on mortality in patients with coronary artery disease.
abstract: BACKGROUND
  High cardiorespiratory fitness and body mass index (BMI) are associated with decreased mortality in patients with coronary artery disease. Our objective was to determine the joint impact of fitness and adiposity measures on all-cause mortality in this subgroup.
  
  
  METHODS
  Coronary artery disease patients (n = 855) enrolled in the Mayo Clinic cardiac rehabilitation program from 1993 to 2007 were included. Fitness levels were determined by cardiopulmonary exercise testing. Patients were divided into low and high fitness by sex-specific median values of peak oxygen consumption and total treadmill time. Adiposity was measured through BMI and waist-to-hip ratio (WHR).
  
  
  RESULTS
  There were 159 deaths during 9.7 ± 3.6 years of mean follow-up. After adjusting for potential confounding factors, low fitness, shorter treadmill time, low BMI, and high WHR were significantly associated with increased mortality. Using low WHR-high fitness group as reference, significantly increased mortality was noted in low WHR-low fitness (hazard ratio 4.2, 95% CI, 1.8-9.8), centrally obese-high fitness (2.3, 1.0-5.4), and centrally obese-low fitness (6.1, 2.7-13.6) groups. Overweight-high fitness (2.2, 0.63-7.4), obese-high fitness (3.2, 0.88-11.4), and obese-low fitness (3.3, 0.96-11.4) subjects did not have a significantly different mortality as compared with the reference group of normal weight-high fitness subjects, whereas normal weight-low fitness (9.6, 2.9-31.8) and overweight-low fitness (6.8, 2.1-22.2) groups had significantly increased mortality.
  
  
  CONCLUSIONS
  Low fitness and central obesity were independently and cumulatively associated with increased mortality in coronary artery disease patients attending cardiac rehabilitation. The association of BMI with mortality is complex and altered by fitness levels.
authors.affiliation: Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA.
authors.forename: Kashish
authors.initials: K
authors.lastname: Goel
authors.forename: Randal J
authors.initials: RJ
authors.lastname: Thomas
authors.forename: Ray W
authors.initials: RW
authors.lastname: Squires
authors.forename: Thais
authors.initials: T
authors.lastname: Coutinho
authors.forename: Jorge F
authors.initials: JF
authors.lastname: Trejo-Gutierrez
authors.forename: Virend K
authors.initials: VK
authors.lastname: Somers
authors.forename: John M
authors.initials: JM
authors.lastname: Miles
authors.forename: Francisco
authors.initials: F
authors.lastname: Lopez-Jimenez
mesh_terms: D050154:Adiposity / Q000502:physiology; D000368:Aged; D015992:Body Mass Index; D003324:Coronary Artery Disease / Q000401:mortality*; D005080:Exercise Test; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009765:Obesity / Q000453:epidemiology; D010101:Oxygen Consumption; D010809:Physical Fitness; D016016:Proportional Hazards Models